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PILATES FOR INJURY PREVENTION: DECREASING KNEE JOINT LAXITY Prepared By Claire Lieberum September 2014 La Playa Pilates and Wellness Center Santa Barbara, CA ABSTRACT Knee pain and knee injuries are a common occurrence in people of all ages (1). This paper will explore the positive effects of a Body Arts and Science InternationalTM based Pilates program on a smaller population, the young and active. Statistics show that knee injuries represent nearly 15% of all sports injuries. Due to the significance of the knee to daily function, and likely cause of disability from injury, 50% of visits to sports doctors are focused on the knee (2). In this case study, the participant presents with bilateral Genu Recurvatum and minor knee pain. She committed to an intensive 10 week (3 times per week) Pilates program and was extremely pleased with the results. Improvement in knee stability, decrease in the severity of the genu recurvatum as well as significant improvement in body awareness during activity all presented following her training. TABLE OF CONTENTS I. Anatomy of the Knee………………………………………………………………… 4 II. Introduction…………………………………………………………………………... 6 III. Case Study…………………………………………………………………………….. 7 IV. Conditioning Program………………………………………………………………… 7 V. Conclusion………………………………………………………………………….....11 VI. Bibliography…………………………………………………………………………. 12 JOINT STRUCTURE OF THE KNEE The knee is the largest joint in the body yet one of the most easily injured. It is a complex joint with many components and therefore has a multitude of parts that are at risk for strain, sprain, dislocation, fractures and tears (3,6). The knee is made up of four bones: the femur, the tibia, the fibula and the patella (kneecap). The joint is a synovial hinge joint that allows the lower leg to move relative to the thigh while supporting the weight of the body. As with all synovial joints, a joint capsule surrounds the bones of the knee to provide strength and lubrication. Ligaments surround the joint capsule and act to reinforce its structure holding the bones in proper alignment (5). At the anterior surface of the knee, the patella is held in place by the patellar ligament. To prevent the femur from sliding medially and laterally, the medial and lateral collateral ligaments support the sides of the joint. Internally, the anterior cruciate ligament (ACL) prevents the femur from sliding backward on the tibia, while the posterior cruciate ligament (PCL) prevents the femur from sliding forward on the tibia. Two C-shaped pieces of cartilage called the medial and lateral menisci act as shock absorbers between the femur and tibia. Small pockets of synovial fluid, known as bursae, surround the knee to reduce the friction from movement of tendons across the surface of the joint (5,6). MUSCLES OF THE KNEE The muscles that create movement of the knee joint are the hamstrings, the quadriceps and the calf muscles. The four muscles of the quadriceps (vastus lateralis, vastus medialis, vastus intermedius, and rectus femoris) act together to create knee extension. Posteriorly, the hamstrings (biceps femoris, semitendinosus, and semimembranosus) work to cause knee flexion along with the gastrocnemius of the calf (4). INTRODUCTION Knee problems are very common, and they occur in people of all ages. Knee pain and knee injuries can interfere significantly with a person’s quality of life, inhibiting a wide range of activities from participation in sports to simply getting up from a chair and walking. The knee joint faces certain challenges: it must be fairly flexible to allow for movement while at the same time, it needs to offer stability and support while standing (8). Knee stability comes from three elements: the structure of the bones, the structure of the ligaments/capsule and the strength of the muscle groups which act on the knee (2). If any of these are deficient due to injury or instability, a person will tend to have ongoing knee problems. Instability of the knee may present with any of the following mechanical symptoms: locking, catching, clicking, or giving way, particularly with twisting movements (10). In the young and active population (a group that typically presents with healthy bone structure) it is important to strengthen the musculature of the knee in order to eliminate pain and keep knees safe from future injuries. According to Jordan D. Metzl, MD, sports medicine physician at the Hospital for Special Surgery in New York City, “when the surrounding muscles are strong, they take pressure off the joints, which allows for greater activity with fewer aches and pains” (11). In cooperation with a strengthening program, it is important to also include a flexibility program (9). Supple, well-stretched muscles are less prone to injury, while less flexible muscles and connective tissues restrict joint mobility, which increases the likelihood of sprains and strains (12). CASE STUDY Name: Sarah* (name has been changed for the privacy of the client) Age: 26 History: Sarah is a fitness instructor with no background of acute knee injury. She presents with minor knee pain and self-proclaimed “weak knees”. Sarah teaches on average 20 exercise classes per week where she must jog, jump, squat, and lunge on a concrete surface. She is concerned that the instability in her knees may result in injury which could possibly result in joblessness. She was a competitive swimmer for 12 years and stated that her knee pain was present at that time as well. Initial assessment found bilateral Genu Recurvatum (hyperextension of the knees) as well as an imbalance between the quadriceps and hamstrings. Sarah’s hyperextension was previously measured by a Physical Therapist at 15 degrees. CONDITIONING PROGRAM Sarah committed to attending Pilates sessions 3 times per week for 10 weeks. Her program was designed utilizing the Body Arts and Science InternationalTM Block system. Within this system, emphasis was placed on strengthening the hamstrings as well as the surrounding muscles that provide knee joint stability. In addition to working on the musculature of the knees, Sarah was also introduced to the 10 Principles of Pilates. Focus was placed on precision of movements and balance between muscle groups. The following are examples of 2 workouts that Sarah was given throughout her 10 week program. WEEK 2 WARM-UP (PERFORMED ON MAT) Exercise Muscle Focus Objectives for Client Roll Down Total Body Body awareness, focus and hamstring stretch Pelvic Curl Hamstrings, Abdominals Warm -up with focus on hamstring control Spine Twist Supine Abdominals Abdominal warm-up, control of tabletop position Single Leg lift Abdominals Abdominal warm-up, control of knee joint angle while moving at hip Leg Circles Abdominals Abdominal warm- up, control of knee joint in extension Notes: In Roll Down, down position was held for 15 seconds each rep to allow for increased hamstring stretch in preparation for exercises. Leg Circles were performed with slight bend in knee due to client's tight hamstrings. FOOT WORK (PERFORMED ON REFORMER) Exercise Muscle Focus Objectives for Client Parallel Heels Hamstrings, Quadriceps Knee flexor and extensor co-activation and strength, Hip extensor strength Parallel Toes Hamstrings, Quadriceps Knee flexor and extensor co-activation and strength, Hip extensor strength V Position Toes Hamstrings, Quadriceps Knee flexor and extensor co-activation and strength, Hip extensor strength Open V Heels Hamstrings, Quadriceps Knee flexor and extensor co-activation and strength, Hip extensor strength Open V Toes Hamstrings, Quadriceps Knee flexor and extensor co-activation and strength, Hip extensor strength Calf Raises Ankle plantar flexors Calf strength, control of knee joint without Hyperextension Prances Ankle plantar flexors Calf strength and stretch, control of knee joint without Hyperextension Notes: Foot work was performed on medium resistance (3 red springs) to allow for increased focus on hamstring activation. Adductor activation and proper leg alignment were emphasized by using a soft ball between knees. Open position foot work was performed in parallel versus external rotation as client's relaxed stance is in ER and internal rotators need strengthening. Calf work performed slowly with "soft knees". ABDOMINAL WORK (PERFORMED ON REFORMER) Exercise Muscle Focus Objectives for Client Hundred Prep Abdominals Abdominal strength, Hip/Knee flexion and extension control Notes: Each rep was performed with extension of the knees and then flexion back to tabletop position. HIP WORK (PERFORMED ON REFORMER) Exercise Muscle Focus Objectives for Client Frog Hip adductors Hamstrings and Hip adductors Hamstrings and Hip adductors Hip adductor strength and Knee extensor control Circles Down/Up Openings Hip adductor strength and Knee extensor control Hip adductor strength and Knee extensor control Notes: Circles and Openings were performed with slight bend in knee due to client's bias toward hyperextension. STRETCHES (PERFORMED ON REFORMER) Exercise Muscle Focus Objectives for Client Standing Lunge Hip flexors, Hamstrings Hip flexor and Hamstring stretch Notes: Held positions for 5 breath cycles. ARM WORK (PERFORMED ON REFORMER) Exercise Muscle Focus Objectives for Client Arms Supine Series Latissimus Dorsi, Triceps Balance in workout, Hip and Knee control in tabletop position LEG WORK (PERFORMED ON MAT WITH MAGIC CIRCLE) Exercise Muscle Focus Objectives for Client Ankles Bent Knees Hip adductors and extensors Hip adductor and extensor strength Notes: Performed in prone position with emphasis on Hamstring control. LATERAL FLEXION/ROTATION (PERFORMED ON MAT) Exercise Muscle Focus Objectives for Client Side lifts Abdominal Obliques Trunk stabilization with adductor control BACK EXTENSION (PERFORMED ON MAT) Exercise Muscle Focus Objectives for Client Back Extension Back extensors Balance in workout, back extensor strength Notes: Followed by rest position and final roll down for Hamstring stretch and body awareness. WEEK 5 WARM-UP (PERFORMED ON CADILLAC USED AS MAT) Exercise Muscle Focus Objectives for Client Roll Down Total Body Body awareness, focus and hamstring stretch Pelvic Curl Hamstrings, Abdominals Warm -up with focus on hamstring control Spine Twist Supine Abdominals Abdominal warm-up, control of tabletop position Leg Changes Abdominals Abdominal warm-up, control of knee joint angle while moving at hip Leg Circles Abdominals Abdominal warm- up, control of knee joint in extension Notes: In Roll Down, down position was held for 15 seconds each rep to allow for increased hamstring stretch in preparation for exercises. Leg circles were performed with straight leg as client has progressed. FOOT WORK (PERFORMED ON CADILLAC) Exercise Muscle Focus Objectives for Client Parallel Heels Hamstrings Hamstring strength and stretch, Knee extensor strength Parallel Toes Hamstrings Hamstring strength and stretch, Knee extensor strength V Position Toes Hamstrings Hamstring strength and stretch, Knee extensor strength, adductor control Open V Heels Hamstrings Hamstring strength and stretch, Knee extensor strength, adductor control Open V Toes Hamstrings Hamstring strength and stretch, Knee extensor strength, adductor control Calf Raises Ankle plantar flexors Calf strength, control of knee joint without Hyperextension Prances Ankle plantar flexors Calf strength and stretch, control of knee joint without Hyperextension Single Leg Heel Hamstrings Hamstring strength and stretch, Knee extensor strength Single Leg Toes Hamstrings Hamstring strength and stretch, Knee extensor strength Notes: Foot work performed slowly with focus on co-activation of leg muscles, control and awareness. ABDOMINAL WORK (PERFORMED ON CADILLAC USED AS MAT) (MC= Magic Circle) Exercise Muscle Focus Objectives for Client Chest Lift (+MC) Abdominals, Hip adductors Abdominal strength, Hip adductor strength Single Leg Stretch Abdominals Abdominal strength, control of knee extension Hamstring Pull 1 Abdominals Abdominal strength, Hamstring stretch HIP WORK (PERFORMED ON CADILLAC) Exercise Muscle Focus Objectives for Client Frog Hip adductors Hip adductor strength and Knee extensor control Circles Down/Up Hamstrings Hip extensor strength and adductor control Walking Hamstrings Hamstring control Notes: Circles and Walking performed with slight bend in knee due to client's bias toward hyperextension. SPINAL ARTICULATION (PERFORMED ON REFORMER) Exercise Muscle Focus Objectives for Client Bottom Lift Abdominals, Hamstrings Hamstring control and strength Notes: Started client with heels on footbar due to hamstring weakness. STRETCHES (PERFORMED ON REFORMER) Exercise Muscle Focus Objectives for Client Standing Lunge Hip flexors, Hamstrings Hip flexor and Hamstring stretch Notes: Held positions for 5 breath cycles. FULL BODY INTEGRATION (FUNDAMENTAL/INTERMEDIATE)(PERFORMED ON REFORMER) Exercise Muscle Focus Objectives for Client Scooter Abdominals Hip and Knee extensor control/strength ARM WORK (PERFORMED ON REFORMER) Exercise Arms sitting series Muscle Focus Latissimus Dorsi, Biceps, Deltoids, Pectorals, Triceps Objectives for Client Trunk Stabilization Notes: Advanced client to Intermediate arm work early due to strength, ability and control during supine arm work. LEG WORK (PERFORMED ON CADILLAC AS MAT, WITH MAGIC CIRCLE) Exercise Objectives for Client Ankles Straight Knees Muscle Focus Hip adductors and extensors Hamstrings Hamstrings and Gluteals Knee flexor strength, Hip extensor strength Hip adductor and extensor strength Notes: Exercises done in prone position with emphasis on Hamstring control. LATERAL FLEXION/ROTATION (PERFORMED ON CADILLAC AS MAT) Exercise Muscle Focus Objectives for Client Saw Hamstrings Hamstring stretch, Back extensor control, Oblique control Exercise Muscle Focus Objectives for Client Back Extension Back extensors Balance in workout, back extensor strength BACK EXTENSION Notes: Followed by rest position and final roll down for Hamstring stretch and body awareness. RESULTS: Following her 10 week program, Sarah stated that she noticed a significant difference in the stability of her knees while teaching as well as decrease in knee pain. She expressed that she is much more aware of her movements and has a greater focus towards proper muscle recruitment in her work and daily life. Not only was there improvement in knee stability, but after hamstring strengthening a decrease in the severity of the genu recurvatum was achieved. Sarah is still able to reach hyperextension in the joint, yet states that the stance “feels uncomfortable”. She also states that she feels stronger as a whole and has become “addicted” to Pilates. CONCLUSION Knee instability remains one of the main factors in knee pain and potential for injury. As shown by this case study, decrease in the severity of joint laxity and muscle imbalance can occur with a proper stretching and strengthening program. The comprehensive Block System from BASITM Pilates was imperative in helping Sarah to gain stability and confidence in the use of her previously “weak knees”. As in the case with Sarah, a comprehensive Pilates program not only is able to address muscle imbalances in weak areas of the body but will strengthen the body and mind as a whole. BIBLIOGRAPHY 1. Mayo Clinic Staff. Diseases and conditions, Knee Pain. 29 March 2013. http://www.mayoclinic.org/diseases-conditions/knee-pain/basics/definition/con20029534 2. McGlaughlin, Ed, MD. Knee Injuries. http://www.sportsmed.info/sportsmed/knee.html 3. Thayer, Matthew BSN, RNFA, ONC, CNOR.(Image) http://www.christuslivewell.org/what-hurts-less-a-total-knee-replacement-or-a-total-hipreplacement-surgery/ 4. Knee Joint Muscles. http://www.sportsinjuryclinic.net/anatomy/human-muscles/knee-joint 5. Taylor, Tim. (Image)Knee Joint. http://www.innerbody.com/image/skel16.html 6. Knee Pain Health Center. http://www.webmd.com/pain-management/knee-pain/picture-ofthe-knee 7. Knee Muscles.(Image) http://kneeexercises.net/knee-muscles/ 8. Knee joint function. http://www.ivysportsmed.com/en/knee-pain/knee-joint-function 9. Tis, Laurie Ph.D., FACSM. 10 January 2012. Basic Knee Injury Prevention. http://www.acsm.org/access-public-information/articles/2012/01/10/basic-knee-injuryprevention 10. Kakarlapudi, Trinath and Bickerstaff, Derek. “Knee instability: isolated and complex.” British Journal of Sports Medicine 2000;34:394-400 11. Stanten, Michele. “Best and Worst Exercises for Bad Knees.” Prevention November 2011. http://www.prevention.com/health/health-concerns/exercises-knee-pain 12. Stretching and strengthening are key to healing and preventing back pain. 30 January 2014. http://www.health.harvard.edu/healthbeat/stretching-and-strengthening-are-key-tohealing-and-preventing-back-pain